May 16, 2007

Pseudoseizures

The confusion in terminology surrounding this condition seems to reflect its complexity.

Oftentimes they are diagnosed in patients who have epilepsy. Along with their epilepsy they may have abnormal interictal EEGs and/or abnormal brain imaging. Therefore it becomes necessary to capture the problematic spells with an EEG to determine whether increasing or adding other antiepileptics is prudent. Usually this has already been done and not worked before a patient is admitted for EEG monitoring.

Capturing non-epileptic spells puts the physician in an uncomfortable position. To sort out what the genesis of the often medically refractory spells is requires a bit of deception. Usually the characteristics of the spells indicate to the physician whether a spell is epileptic or not. The bind is that without capturing these one can never know for sure whether they are epileptic. Unlike other psychogenic symptoms, Viz. other manifestations of somatoform disorders, pseudoseizures can be documented with a normal ictal EEG. For pseudoseizures, there is a test to prove that the somatoform disorder is not real or organic. I think the deception - if there is any - enters when the physician directs testing to gather evidence against the patient. Of course this could be viewed otherwise. By proving that the spells are not epileptic a patient can be spared potentially toxic medications and medical care not directed at the underlying problem, one more psychologic or social.

This post previously detailed what I am calling deception taken to its greatest extent. I previously didn't have a discussion of the difficulty inherent in diagnosing and treating pseudoseizures, nor did I state the unsavoriness in the following interaction. An attending told a woman with suspicious spells that he was not going to make her angry, which triggered her typical spells, but that there was another possible way to induce a seizure. A alcohol pad on the neck could cause a temperature differential and a convection that might induce a seizure. One alcohol pad was not enough so he added another. The woman became unresponsive and then began shaking. The attending took off the alcohol pad and wiped her neck with water. She stopped within a couple minutes and was very lethargic.

The most disturbing thing about this is that in identifying the spells as non-epileptic, the neurologist can walk away without having really helped the patient. The most important part of the pseudoseizure hospital admission is when the physician addresses the pseudoseizures and involves therapists and possibly psychiatrists in the patient's care. This is usually a very difficult conversation, but when done with compassion and understanding, it can be therapeutic.